Name:
Address:
City:
State:
Zip:
Phone:
E-Mail Address:
Date of Birth
Weight:
Height:
Athletic Information:
Current Amateur Team:
Position:
Shoots/Catch:
Left
Right
Goals-Assists/G.A.A:
Coach's Name:
Coach's Phone:
High School:
High School:
Graduation Date:
H.S GPA:
360 McClurg Road * Boardman, Ohio 44512
330.965.7500 * Fax: 330.965.9923 *
rrusso@fireworks.com
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